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Summary The management of high-risk benign breast disease (BBD) is changing because of improvements in radiological and pathological analysis. We sought to determine the current practice recommendations of breast health professionals in managing patients with high-risk BBD. We surveyed members of the Canadian Society of Surgical Oncology, Canadian Association of General Surgeons and Canadian Association of Radiologists. The survey contained demographic and case-based questions concerning management of high-risk benign breast lesions. Participants were asked for their recommendations and opinions regarding future risk of breast cancer as well as the role of chemoprevention. There was no consistency among the 41 respondents in the treatment recommendations for any of the high-risk benign conditions, and the lifetime risk associated with classic lobular carcinoma in situ was vastly underestimated. Education and evidenced-based guidelines are urgently needed to ensure more uniform practice nationally.

Background The objective of this study was to compare the effect of thoracic paravertebral block (TPVB) and local anesthetic (LA) on persistent postoperative pain (PPP) 1 year following breast cancer surgery. Secondary objectives were to compare the effect on arm morbidity and quality of life. Methods Women scheduled for elective breast cancer surgery were randomly assigned to either TPVB or LA followed by general anesthesia. An NRS value of >3 at rest or with movement 1 year following surgery defined PPP. Blinded interim analysis suggested rates of PPP much lower than anticipated, making detection of the specified 20 % absolute reduction in the primary outcome impossible. Recruitment was stopped, and all enrolled patients were followed to 1 year. Results A total of 145 participants were recruited; 65 were randomized to TPVB and 64 to LA. Groups were similar with respect to demographic and treatment characteristics. Only 9 patients (8 %; 95 % CI 4–14 %) met criteria for PPP 1 year following surgery; 5 were in the TPVB and 4 in the LA group. Brief Pain Inventory severity and interference scores were low in both groups. Arm morbidity and quality of life were similar in both groups. The 9 patients with PPP reported shoulder-arm morbidity and reduced quality of life. Conclusions This study reports a low incidence of chronic pain 1 year following major breast cancer surgery. Although PPP was uncommon at 1 year, it had a large impact on the affected patients’ arm morbidity and quality of life.

The diagnostic phase of care is an anxiety-provoking and stressful experience for the potential breast cancer patient. A multidisciplinary team of breast cancer specialists embarked on a new initiative to pilot a Rapid Diagnosis and Support (RADS) Clinic to coordinate the diagnostic workup and nursing support for patients with a high probability of breast cancer.Consecutive patients with an initial diagnostic imaging classified as BI-RADS 5 were invited to participate in this 1-year prospective study. Coordination of diagnostic imaging workup and nursing support were provided by a nurse navigator. Wait times were evaluated at several intervals of care. Satisfaction surveys were given to study participants and compared to scores from patients who did not go through RADS clinic.A total of 211 patients participated in the RADS clinic. Biopsy wait times improved from a mean of 7 to 3 days (p0.001), pathology from 3.9 to 3.3 days (p0.001), surgical consultation from 16.1 to 5.9 days (p0.001), and operative wait times from 31.5 to 24.1 days (p = 0.042). There was a 95.3 % satisfaction rate with the RADS clinic with significantly improvement in patients' sense of an understanding of the treatment plan (p = 0.031), timeliness of tests (p = 0.045), and timeliness of results (p = 0.0419).The RADS clinic significantly improved diagnostic wait times and satisfaction scores for patients with a high probability of diagnosis of breast cancer and can serve as an innovative service delivery model for other breast care centers.

To determine whether patients with isolated systolic hypertension (ISH) undergoing non-cardiac surgery have a higher incidence of perioperative myocardial ischemia than normotensive patients and hence a greater risk for perioperative adverse events.After obtaining Research Ethics Board approval, patients were recruited to either an ISH group (systolic blood pressure [SBP] 140 mmHg with diastolic blood pressure [DBP] 90 mmHg) or a normotensive group (SBP 140 mmHg and DBP 90 mmHg), according to their resting preoperative blood pressure. The primary outcome was the overall incidence of perioperative myocardial ischemia (PMI) as determined by 48-hr ambulatory Holter monitoring. P values ≤ 0.05 were considered to be statistically significant.A total of 312 (150 ISH and 162 normotensive) patients completed the study. Orthopedic surgery was the most frequent surgical procedure in both groups. The overall incidence of PMI was 19.7% in the ISH group compared with 18.8% in the normotensive group (difference 0.9%; 95% confidence interval [CI], -7.9% to 9.8%). The overall incidence of adverse events was 4.0% in the ISH group compared with 1.9% in the normotensive group (difference 2.2%; 95% CI, -1.6% to 5.9%).In this study, we chose to examine ISH as potential cardiac risk factor for patients undergoing non-cardiac surgery. The incidence of myocardial ischemia, a surrogate outcome, was similar in the two groups. The relatively high incidence of myocardial ischemia (19.2%) was of particular interest in this relatively low cardiac risk surgical population. (ClinicalTrials.gov number, NCT01237652).

Background: A systematic review of the literature identifying regional collaborations in surgical practice examining practices related to quality improvement. Methods: The MEDLINE, EMBASE, and Cochrane Library databases, were searched for published reports of regional collaborations in the surgical community relating to initiatives to enhance quality improvement, quality of care, patient safety, knowledge transfer, or communities of practice. Results: Seven collaborative initiatives met the inclusion criteria and were included in the systematic review of the evidence. Motivations for initiating collaborations were often in response to external demands for performance data. Changes in the processes of clinical care and improvements in clinical outcomes were reported on the basis of the collaborative efforts. Significant improvements in clinical outcomes such as decreases in mortality rates, lower duration of postoperative intubations, and fewer surgical-site infections were reported. Quality improvement process measures were also reported to be improved across all of the collaborative initiatives. Success factors included (a) the establishment of trust among health professionals and health institutions; (b) the availability of accurate, complete, relevant data; (c) clinical leadership; (d) institutional commitment; and (e) the infrastructure and methodological support for quality management. Conclusions: A community of practice framework incorporating the success elements described in the systematic review of the literature can be used as a valuable model for collaboration amongst surgeons and healthcare organizations to improve quality of care and foster continuing professional development.

To evaluate the influence of aging on the increase in endogenous glucose production that follows injury, we studied 22 fully resuscitated, clinically stable, previously healthy patients agedor = 30 yr oror = 60 yr admitted to hospital following injury, and 11 healthy volunteers in the same age groups. Endogenous glucose production was determined using a primed constant infusion of D-glucose-6,6-2d2. Urine cortisol and C-peptide were markedly higher in patients than volunteers (both P0.01), and urine C-peptide was lower in older than in younger patients (P0.05). Urine cortisol increased as a function of the interaction of age and Injury Severity Score (ISS) (r2 = 0.40, P0.001). Intracellular water was markedly lower and extracellular water greater in patients compared with volunteers (both P0.001), reflecting the loss of body cell mass and expansion of the extracellular space following injury. Endogenous glucose production (milligrams per minute per liter intracellular water) was best described as a function of ISS and age-ISS interaction (r2 = 0.35, all P0.05), and was increased 56% and 78% in younger and older patients, respectively, in comparison with the respective volunteer groups. Endogenous glucose production following injury increases in relation to the severity of injury and patient age. Greater cortisol elaboration and diminished insulin secretion in older patients may contribute to this age effect.

OBJECTIVE To quantify glucose balance related to continuous arteriovenous hemofiltration (CAVH) when a glucose-rich replacement fluid is used for the plasma ultrafiltrate removed. DESIGN Prospective, nonintervention study. SETTING Medical/surgical and cardiac surgical intensive care units of a university hospital. PATIENTS Critically ill patients (n = 20) with acute oliguric renal failure undergoing CAVH. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Timed collections of CAVH effluent were analyzed and other observations were made. Serum creatinine and blood urea nitrogen concentrations decreased substantially during CAVH in each patient. The mean measured glucose concentration of the replacement fluid (Dianeal 1.5%) was 1.40 +/- 0.11 (SD) g/dL (77 +/- 6 mmol/L) and rate of infusion was 1.39 +/- 0.43 L/hr. Effluent volume was 1.51 +/- 0.49 L/hr and glucose was 0.47 +/- 0.10 g/dL (26 +/- 5 mmol/L). The glucose content of the replacement fluid infused was consistently and substantially greater than that value of the effluent removed during the same period. Thus, the average net glucose uptake in relation to the CAVH circuit was 11.9 +/- 3.1 g/hr (range 4.3 to 17.6). Serum glucose concentrations increased in each patient with initiation of CAVH (from 135 +/- 44 to 278 +/- 80 mg/dL [7.4 +/- 2.4 to 15.3 +/- 4.4 mmol/L]; p < .001). Negative fluid balance achieved during CAVH was approximately 100 mL/hr. CONCLUSIONS CAVH using predilution with replacement fluid is effective in managing uremia and fluid overload in critically ill patients. The use of a glucose-rich replacement fluid is accompanied by the net uptake of large amounts of glucose, approaching 300 g/day on average in our patients and representing a major exogenous calorie source. This finding has important implications for the metabolic management of critically ill patients during CAVH and should be taken into account in prescribing their nutritional support.

This study examined themes relevant to health-related quality of life as identified by patients undergoing major surgery and by health care providers. Semi-structured interviews were conducted with 52 patients undergoing major abdominal, cardiac, orthopedic, thoracic, or vascular surgical procedures and 33 health professionals from various disciplines. A total of 58 themes were identified by content analysis. These themes were categorized into 6 domains. These were: physical well-being (14 themes), emotional well-being (13 themes), concern about quality of care (12 themes), social well-being (12 themes), cognitive preparation (4 themes), and spiritual well-being (3 themes). In general, we found that most aspects of health-related quality of life were common across various major surgical procedures and between patients and health care providers. However, when we examined the coverage of these themes in seven commonly-used health-related quality of life instruments, we found that many of the most frequently mentioned themes were not assessed with the available measures. A new evaluative instrument tailored to patients undergoing major surgery may therefore be warranted.

Older trauma patients are less tolerant of glucose loads than are young patients, in part as a result of diminished insulin response. We hypothesized that diminished insulin responses result from reduced pancreatic sensitivity to beta-adrenergic stimulation.We studied healthy subjects prospectively at a clinical investigation unit, to compare young (n = 6, mean age 21 [standard deviation {SD} 2] yr) and older people (n = 6, mean 63 [SD 2] yr). Paired studies of isoproterenol infusion, alone and in conjunction with a 2-hour hyperglycemic glucose clamp, were conducted in each subject. Heart rate, serum insulin concentration and other hemodynamic, biochemical, and physiologic variables were measured.Heart rate increased less markedly in response to isoproterenol in older than in young subjects (p0.01). Serum insulin during infusion accompanied by hyperglycemic clamp was also lower (467 [SD 135] pmol/L in older v. 755 [SD 284] pmol/L in young subjects, p0.05), despite similar hyperglycemia. Whole-body disposal of exogenous glucose was lower in older (5.8 [SD 1.7] mg/kg/min) than in young subjects (9.6 [SD 3.9], p0.05).Heart rate and serum insulin responses to combined isoproterenol infusion and glucose loading were both lower in healthy older subjects than in the young. Diminished tissue sensitivity to beta-adrenergic signals may contribute to the impaired insulin response and exaggerated glucose intolerance displayed by older patients after injury and during acute illness.

Background: Tissue injury following ischemia–reperfusion is mediated in part by free oxygen radicals. We hypothesized that perioperative micronutrient supplementation would augment antioxidant defenses, minimize muscle injury, and minimize postoperative decreases in muscle strength and physical function following abdominal aortic aneurysmectomy. Setting: A university-affiliated hospital and regional referral center. Design: A randomized, double-blind, placebo-controlled trial of supplementation with beta-carotene, vitamins C and E, zinc, and selenium for a period of 2––3 weeks prior to surgery and 1 week thereafter. Study population: Patients undergoing elective abdominal aortic aneurysmectomy ( n =18 per group). Principal measurements: Handgrip and other measures of strength and physical function. Results: Handgrip and quadriceps strength decreased following surgery, but not to a significantly different extent in the placebo and supplemented groups. Self-rated physical function decreased following surgery in the placebo group and was preserved in the supplemented group. Conclusions: Perioperative supplementation with micronutrients with antioxidant properties has limited effects on strength and physical function following major elective surgery.

OBJECTIVE: The authors set out to determine whether immediate enteral feeding minimizes early postoperative decreases in handgrip and respiratory muscle strength. SUMMARY BACKGROUND DATA: Muscle strength decreases considerably after major surgical procedures. Enteral feeding has been shown to restore strength rapidly in other clinical settings. METHODS: A randomized, controlled, nonblinded clinical trial was conducted in patients undergoing esophagectomy or pancreatoduodenectomy who received immediate postoperative enteral feeding via jejunostomy (fed, n = 13), or no enteral feeding during the first 6 postoperative days (unfed, n = 15). Handgrip strength, vital capacity, forced expiratory volume in one second (FEV1), and maximal inspiratory pressure (MIP) were measured before surgery and on postoperative days 2, 4, and 6. Fatigue and vigor were evaluated before surgery and on postoperative day 6. Mobility was assessed daily after surgery using a standardized descriptive scale. Postoperative urine biochemistry was evaluated in daily 24-hour collections. RESULTS: Postoperative vital capacity (p < 0.05) and FEV1 (p = 0.07) were consistently lower (18%-29%) in the fed group than in the unfed group, whereas grip strength and maximal inspiratory pressure were not significantly different. Postoperative mobility also was lower in the fed patients (p < 0.05) and tended to recover less rapidly (p = 0.07). Fatigue increased and vigor decreased after surgery (both p < or = 0.001), but changes were similar in the fed and unfed groups. Intensive care unit and postoperative hospital stay did not differ between groups. CONCLUSIONS: Immediate postoperative jejunal feeding was associated with impaired respiratory mechanics and postoperative mobility and did not influence the loss of muscle strength or the increase in fatigue, which occurred after major surgery. Immediate postoperative enteral feeding should not be routine in well-nourished patients at low risk of nutrition-related complications.

Hyperglycemia and glucose intolerance are characteristic of both the metabolic responses to injury and normal aging. To evaluate the interaction of such changes we conducted hyperglycemic glucose clamp studies (2-hour) in previously healthy young (20 +/- 4 years, Mean +/- SD) and older (73 +/- 9 years) trauma patients and volunteers (23 +/- 1 and 68 +/- 5 years), determining whole-body glucose disposal and insulin responses to hyperglycemia. Injury Severity Scores were similar in the young and older patient groups (range, 17-30). Plasma glucose levels were greater in patients than volunteers in both the basal and hyperglycemic periods. Basal serum insulin and C-peptide levels were similar among groups, but during hyperglycemia both were markedly higher in young patients than older (and both volunteer groups). Whole-body disposal of exogenous glucose was substantially lower in patients than volunteers and in the older groups. Aging has a major impact on postinjury metabolism, being associated with exaggerated glucose intolerance and diminished insulin responses to glucose infusion. These findings have important implications for the metabolic and nutritional care of older patients following trauma and during critical illness.

Our objective was to determine the effect of perioperative epidural anaesthesia and analgesia on the increase in energy expenditure which accompanies major elective abdominal surgery in a prospective, randomized study. Eight patients undergoing elective resections of the colon and/or rectum received general anaesthesia alone (nitrous oxide, oxygen, and isoflurane, supplemented with intravenous fentanyl to a maximum of 10 μg · kg−1), and 12 patients received perioperative epidural anaesthesia and analgesia using lidocaine (carbonated lidocaine 2% with epinephrine 1:200,000, 20 ml over 30 min) and morphine (preservative-free morphine 0.10 mg · kg−1 after catheter insertion and 0.05 to 0.10 mg · kg−1 every 12 hr as needed until the morning following surgery) via a lower lumbar catheter in addition to general anaesthesia. Respiratory gas exchange was measured using a metabolic cart and canopy system early on the morning of surgery, six hours postoperatively, and on the first and second postoperative mornings. Parenteral analgesic administration (P < 0.001) and visual analogue pain scores (P < 0.05) were lower in the patients receiving epidural anaesthesia and time to first parenteral analgesia was longer (P< 0.005). Oxygen consumption, carbon dioxide production, and energy expenditure increased after surgery (all P < 0.001) but were very similar in the two groups (all P ≥ 0.8) before and after surgery. Despite substantial effects on postoperative pain, we conclude that oxygen consumption and energy expenditure following major abdominal surgery are not diminished by perioperative epidural anaesthesia and analgesia.

Although gastroduodenal ulcers rarely perforate during critical illness, this occurrence causes specific and difficult problems of diagnosis and management. In our review of the records of 19 critically ill patients whose ulcers perforated, we found that classical symptoms were frequently absent. The perforations often were manifested by nonspecific clinical events, such as unexplained ileus or hypotension. Diagnosis was typically delayed and on occasion was first suspected after observing pneumoperitoneum on a routine x-ray. While the ulcers were characteristically very large (greater than 2 cm), minimal inflammation surrounded them. Mortality was 56% in the 16 patients whose perforations were diagnosed before death or discharge. Fifteen patients were treated with simple patching of the ulcer. Perforated ulcers in critically ill patients differ in several important ways from those occurring in otherwise healthy individuals.